#IA_PM_2 Anticoagulant management improvements

Description :

MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, in the first performance year, 60 percent or more of their ambulatory care patients receiving warfarin are being managed by one or more of these clinical practice improvement activities: Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care*, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program. The performance threshold will increase to 75 percent for the second performance year and onward. Clinicians would attest that, 60 percent for first year, or 75 percent for the second year, of their ambulatory care patients receiving warfarin participated in an anticoagulation management program for at least 90 days during the performance period.

Subcategory Name :

Population Management

Activity Weighting :

Description :

Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following: Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; plan of care for chronic conditions; and advance care planning; Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target; Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions; Use panel support tools (registry functionality) to identify services due; Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or Routine medication reconciliation.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_5 Engagement of community for health status improvement

Description :

Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_4 Glycemic management services

Description :

For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having: For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that: a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and b) Is reassessed at least annually. The performance threshold will increase to 75 percent for the second performance year and onward. Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.

Subcategory Name :

Population Management

Activity Weighting :

Description :

Provide episodic care management, including management across transitions and referrals that could include one or more of the following: Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or Managing care intensively through new diagnoses, injuries and exacerbations of illness.

Subcategory Name :

Population Management

Activity Weighting :

Description :

Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; Integrate a pharmacist into the care team; and/or Conduct periodic, structured medication reviews

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_14 Implementation of methodologies for improvements in longitudinal care management for high risk patients

Description :

Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_8 Participation in CMMI models such as Million Hearts Campaign

Description :

Participation in CMMI models such as the Million Hearts Cardiovascular Risk Reduction Model

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_9 Participation in population health research

Description :

Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_1 Participation in systematic anticoagulation program

Description :

Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, patient self-management program)for 60 percent of practice patients in year 1 and 75 percent of practice patients in year 2 who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors).

Subcategory Name :

Population Management

Activity Weighting :

High

#IA_PM_12 Population empanelment

Description :

Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team. Empanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management. Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_11 Regular review practices in place on targeted patient population needs

Description :

Implementation of regular reviews of targeted patient population needs which includes access to reports that show unique characteristics of eligible professional’s patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_3 RHC, IHS or FQHC quality improvement activities

Description :

Participating in a Rural Health Clinic (RHC), Indian Health Service (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.

Subcategory Name :

Population Management

Activity Weighting :

High

#IA_PM_10 Use of QCDR data for quality improvement such as comparative analysis reports across patient populations

Description :

Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_7 Use of QCDR for feedback reports that incorporate population health

Description :

Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.

Subcategory Name :

Population Management

Activity Weighting :

High

#IA_PM_6 Use of toolsets or other resources to close healthcare disparities across communities

Description :

Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_1 Participation in Systematic Anticoagulation Program

Description :

Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program) for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, who receive anti-coagulation medications (warfarin or other coagulation cascade inhibitors).

Subcategory Name :

Population Management

Activity Weighting :

High

#IA_PM_2 Anticoagulant Management Improvements

Description :

Individual MIPS eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, for 60 percent of practice patients in the transition year and 75 percent of practice patients in Quality Payment Program Year 2 and future years, their ambulatory care patients receiving warfarin are being managed by one or more of the following improvement activities:
• Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;
• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;
• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; and/or
• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.

Subcategory Name :

Population Management

Activity Weighting :

High

#IA_PM_3 RHC, IHS or FQHC quality improvement activities

Description :

Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting , and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.

Subcategory Name :

Population Management

Activity Weighting :

High

#IA_PM_4 Glycemic management services

Description :

For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having:
For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that:
a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and
b) Is reassessed at least annually.The performance threshold will increase to 75 percent for the second performance year and onward.
Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.

Subcategory Name :

Population Management

Activity Weighting :

High

#IA_PM_5 Engagement of community for health status improvement

Description :

Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_6 Use of toolsets or other resources to close healthcare disparities across communities

Description :

Take steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_7 Use of QCDR for feedback reports that incorporate population health

Description :

Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes, including for vulnerable populations.

Subcategory Name :

Population Management

Activity Weighting :

High

#IA_PM_9 Participation in population health research

Description :

Participation in research that identifies interventions, tools or processes that can improve a targeted patient population.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_10 Use of QCDR data for quality improvement such as comparative analysis reports across patient populations

Description :

Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcome).

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_11 Regular Review Practices in Place on Targeted Patient Population Needs

Description :

Implementation of regular reviews of targeted patient population needs, such as structured clinical case reviews, which includes access to reports that show unique characteristics of eligible clinician's patient population, identification of vulnerable patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_12 Population empanelment

Description :

Empanel (assign responsibility for) the total population, linking each patient to a MIPS eligible clinician or group or care team.
Empanelment is a series of processes that assign each active patient to a MIPS eligible clinician or group and/or care team, confirm assignment with patients and clinicians, and use the resultant patient panels as a foundation for individual patient and population health management.
Empanelment identifies the patients and population for whom the MIPS eligible clinician or group and/or care team is responsible and is the foundation for the relationship continuity between patient and MIPS eligible clinician or group /care team that is at the heart of comprehensive primary care. Effective empanelment requires identification of the “active population” of the practice: those patients who identify and use your practice as a source for primary care. There are many ways to define “active patients” operationally, but generally, the definition of “active patients” includes patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care.

Subcategory Name :

Population Management

Activity Weighting :

Description :

Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:
• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;
• Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target; such as a CDC-recognized diabetes prevention program;
• Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;
• Use panel support tools (registry functionality) to identify services due;
• Use predictive analytical models to predict risk, onset and progression of chronic diseases; or
• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_14 Implementation of methodologies for improvements in longitudinal care management for high risk patients

Description :

Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:
Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;
Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or
Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.

Subcategory Name :

Population Management

Activity Weighting :

Description :

Provide episodic care management, including management across transitions and referrals that could include one or more of the following:
Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or
Managing care intensively through new diagnoses, injuries and exacerbations of illness.

Subcategory Name :

Population Management

Activity Weighting :

Description :

Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following:
Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups;
Integrate a pharmacist into the care team; and/or
Conduct periodic, structured medication reviews.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_17 Participation in Population Health Research

Description :

Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_18 Provide Clinical-Community Linkages

Description :

Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_19 Glycemic Screening Services

Description :

For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_20 Glycemic Referring Services

Description :

For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.

Subcategory Name :

Population Management

Activity Weighting :

Medium

#IA_PM_21 Advance Care Planning

Description :

Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.